Thursday, February 11, 2010

The GP Conundrum—Whither the Future?

The GP Conundrum—Whither the Future?
Dr David KL Quek, MMA News, February 2010
“A doctor must work eighteen hours a day and seven days a week.  If you cannot console yourself to this, get out of the profession.”  ~ Martin H. Fischer
“A physician is obligated to consider more than a diseased organ, more even than the whole man - he must view the man in his world.”  ~ Harvey Cushing
“To me the ideal doctor would be a man endowed with profound knowledge of life and of the soul, intuitively divining any suffering or disorder of whatever kind, and restoring peace by his mere presence”.  ~  Henri Amiel
“Despite all our toil and progress, the art of medicine still falls somewhere between trout casting and spook writing.”  ~ Ben Hecht, Miracle of the Fifteen Murderers

Of late the general practitioner (GP) has become a marked and endangered species, or so it seems.
The private medical practitioner, for so long the backbone of the primary healthcare structure for Malaysia appears to be teetering on the brink of corrosive extinction, if not emasculation. The GP’s role has become increasingly deprecated, marginalized and severely delimited, even competed against directly and indirectly by government-backed 1Malaysia clinics, run by medical assistants and nurses.
This is especially poignant when we know that whenever someone falls ill and/or needs medical care, some 62% of our nation’s population would seek direct treatment from GPs for the initial health concerns (3rd National Health & Morbidity Survey, 2006).
GPs remain the very affordable, conveniently-sited and perhaps the most efficiently accessible approach for primary healthcare for most urban as well as for suburban citizens.
Yes, it is true that many of these encounters are reimbursed from out-of-pocket (OOP) mechanisms, which seem to bug health economists these days. But, the cost of such one-to-one care, then and now is still very reasonable and affordable, and often does not escalate as high or as frequently as inflation!
In more rural or remote locations, many patients often find hard-earned means to seek treatment from caring family-based GPs who are often the preferred healthcare provider, rather than to avail themselves to public healthcare clinics where wait times and changing personnel provide a less than continuous system of care. Many have complained of disjointed, impersonal care, which appears to be inherent in our present public healthcare system of rotating transient medical officers or assistants, who come and go…
Thus, despite lingering perceptions by certain authorities that the care provided by GPs are piecemeal and sometimes fractured and deficient, many people when asked would declare that in most cases, the care provided by GPs are what had made our Malaysian citizens as healthy as they have been these many decades following Merdeka!
More than the usual coughs and colds, cuts and scratches, fevers and diarrhoeas, chronic ailments (such as hypertension, diabetes, asthma, arthritis, etc) are also given sufficiently good care by many GPs who provide comprehensive medical services to entire families and their children’s families too. Sometimes, different GPs acquire different reputations for being that singular ‘specialist’ for unremitting fevers, for hypertension, for asthma, and so on.
When I was young, Dr Alice Low from Johor Bahru saved me many times over from my debilitating asthmatic attacks, and generously provided sampled inhalers when my family could ill afford to buy them on such a regular basis. Despite my nearly monthly attacks, I was thankfully, never ill enough to have been hospitalized due to her dedicated care, nearly a half-century ago. I finally outgrew my wheezy tendency in my mid-teens, perhaps a legacy of her care and therapy. Thank you Dr Low!
Dr Alice Low (84yrs, left standing), at Dr Martin's 95th birthday, seated. Photo Courtesy Dr Wong Yin Onn, JB

My late father, who passed away at 80 years last year, had severe hypertension from young. He received ‘special care’ from Dr Ho Ung Chek along Jalan Terus, JB, for nearly 20 years. When Dad finally died, he did not have LVH, but the scourge of microvascular effects led to some mild Parkinsonism. He did not have the privilege of better, more efficacious drugs then. But I am convinced he did get the best that medicine and good doctoring could provide then, under those trying circumstances, at affordable and cost-effective prices.
Dr Ho used to work very long hours, from 9 in the morning to nearly 9 at night, six days a week. I did not remember a time when he took leave. When I accompanied my Dad sometimes on Saturday afternoons, Dr Ho was always there for his throngs of patients who would patiently queue for hours to access his ‘special’ touch, his singular ‘knowing’ therapeutic expertise! He spoke little, but had a kindly, approachable façade and calm nature that belies his true quiet authoritative professionalism. In some ways doctors such as these have helped nurture my enduring interest in medicine.
I salute Drs Low, Ho and all others who I believe continue to live on in the thousands of GPs around the country—plying their dedicated quiet practice, looking after so many patients, so many families, that can only leave behind lasting legacies of health, confident connection and friendship…
But times and medical practice have changed somewhat. It is difficult to quantify how much and how this has impacted upon the GP, the medical practitioner, who engages in direct patient care.
There’s greater depth and breadth of old and new medical disciplines, which necessitate constant updating and continuing professional development (CPD). Knowledge and even basic concepts continue to evolve and shift into more plausible, more evidence-based certainty, although these stand correctible with newer findings and research.
Furthermore, the physician is called upon to withstand the onslaught of rehashed mumbo-jumbo and complementary alternative therapies, which continue to mindlessly but alluringly erode into the impassive cold sanctum of scientific medical practice.
The doctor has to steel himself/herself from such quackery, which is seductively simpler to adopt and to share folie-a-deux ideation with our increasingly credulous patients (and even some doctors themselves!). Many are generally becoming more gullible than scientifically rigorous! How can we differentiate truths from pseudoscientific gobbledygook, and avoid the lure of lucre from overwhelming our humdrum practices?
The question arises whether the ordinary doctor can maintain his level of competence and knowledge base so as not to endanger his ward—the patients. Worldwide, the medical practitioner is called upon to maintain his expertise and standard of care, his core competency through rigorous and standardized continuing educational programmes. Most are voluntary, but increasingly, many regulatory authorities are beginning to impose mandatory proof of keeping up with currency of medical knowledge.
Unfortunately however, there has been a general passivity about many of our GPs, our doctors here in Malaysia. It is estimated that as few as only 10-15 percent of our doctors routinely attend CPD programmes. The majority simply sit on their past educational base, and continue regardless without venturing into newer advances in a systematic way.
This will have to change. Doctors have to be more proactive in learning and maintaining their skills and knowledge, if they are to do justice to their profession, no matter their conviction that ‘all’ of medicine had been learnt in his/her tenure as a medical student! So how do we encourage or even mandate such a change, a requirement, to ensure that modern medicine is now as scientific and as evidence-based as can be?
GPs must look within themselves to re-engineer their modus operandi, their ways of medical practice even. GPs have to emerge from their cocooned complacency that simply serving quietly and earnestly behind long hours of general practice will suffice. It is not.
More is now expected, it is no longer simply more of the same, with an unending gravy train of endless patient queues. Fee-for-service models may also need a re-tweaking, as more and more primary care services are moving toward a capitation/gate-keeping and pay-for-performance model.
Will the solo practitioner be extinct? Can he/she cope with the rising expectations and keener competition to be better, more efficient, more diverse yet more encompassing?
Or would larger group practices with greater diverse interests and greater pooling of resources and capacities be the trend for the future?
There is louder and louder talk of locale-base patient-registered medical practices which will be regionally reimbursed through a single payer system. Will the GP be prepared, and if so, how can this be made better or improved upon? There is also talk of co-payment possibilities to reduce abuse and over-use of amenities or medications, even separation of pharmacy-dispensing roles…
Would the GP be ready to act as responsible financial-controller and gate-keeper, with that onerous duty on who to continue to treat and who to refer forward to tertiary specialist care, on a timely yet medically-defensible way?
Would he or she be ready to look after returned patients, who have been referred back for chronic care management and rehabilitation, after acute tertiary therapies, including major surgeries?
Will our GPs be up to the mark of being the primary care-led physician who can help keep the cost of health care as low as possible?
Would the GP be trusted to ensure that the societal interests be the primary concern, while maintaining a high performance standard, which enhances measureable and auditable healthcare targets?
Will he or she be ready to be rewarded for performance rather than rely on the lure of pure profits, alone? Are the GP’s skills sufficient at this juncture to cater to these potential and impending challenges?
Therefore, as can be predicted, there will be tremendous emerging transformations, which would continue to shatter the equanimity of more and more GPs—creating in its wake more uncertainties and piqued disappointment.
There is thus, the growing spectre of more regulations, possible accreditation plans for both professional/practice and clinic standards, and possible recertification/revalidation moves which only add to the litany of more bad and cumbersome news.
Then too, there’ve been moves to introduce family medicine specialists (FMS) or family physicians as another tier of ‘specialist’ primary care doctor, who supposedly would be better equipped to enhance modern day primary care practice…
I know that many GPs are quite distressed by all these developments. Many have complained loudly and are understandably angry because they feel so hopeless as events continue to unravel around them with such paces that seem to leave them behind. Some complain that they seem to have been neglected and left out of the loop, whenever discussions on their future take place.
Yet GPs are supposed to have been represented. They have various groups, which purport to be acting on their behalf, with the MMA being the largest body representing them. Yet, these do not appear to be enough. Whenever any call is made for GPs to come forward to be heard, only a select handful turns up to be counted.
In January 2010, in the wake of the contentious 1Malayia clinic launching, a dialogue with the Health Minister saw just some 13 GPs out of 25 MMA members, who could find the time and effort to make a presence, and let their voices be heard.
This perceived apathy and lack of forceful passion is deafeningly disturbing, and gives the impression to the authorities that GPs are malleable and thus perhaps can be led without too much pressure. Thus, events continue to unfold, and the dice appears to have been cast…
But the brutal honest truth is that GPs appear to be floundering, like fish out of water. The tide of good ole times seems to have ebbed. We appear not to have a cohesive or comprehensive General Practice policy, which is devised by GPs themselves, when this should really be the optimum practice.
As president, I have been publicly censured for opposing the popular 1Malaysia clinics, and told in no uncertain terms that I should simply lead, and that the GPs would follow. Even another medical group leader suggested that since some proposed changes are good for the profession, such upgrading efforts should be pushed and led, not necessarily with input by the GPs on the ground! Lead, not by consensus or feedback all the time, I’ve been told… Let a few disgruntled ones make some noises, but as leader, just do the ‘right’ thing by what MOH or some of us, feel is right…
But I choose to listen to the background noises, because many GPs did email or sms text me their rising discomfort level, their rightful concerns, their livelihood realities, their professional right. Yes, we do need more doctors to speak out and be counted. Now we should do even more!
It is with this in mind that the MMA has through its PPS, initiated a Primary Care Group which is striving to champion the policies of the GP. The Academy of Family Physicians, and some interested GP interest groups are also involved.
We are planning a GP Summit where we hope all the issues, which pertain to the GP and its future challenges and scenarios can be discussed, debated and finally arrived at, in a comprehensive policy document which will enhance and protect the interests and ultimate practice conditions of all GPs.
We need as many of you as possible to support this initiative. Do come forwards to make this a great success with all your input, to help shape our collective future! This is in your hands!
For those in the public sector, it is also incumbent on most of you to consider seriously that your future would also depend on the many policy changes, which are coming on-stream very soon. You too must come forward to join us in the campaign to ensure that our voices about our future be heard.
For once in a long while, please come forwards and make your own future! Doctors of Malaysia, it is time to unite and be counted, lest we be accused of engineering our own demise through neglect and apathy…

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